Confidential
Naturopathic Medicine
__DIANNA HENSON, ND
1911 Mountain View Lane, Ste 200 - Forest Grove, OR 97116
Phone: 503-702-0068 - Fax: 503-357-2527
Patient Name: ____________ Today’s Date: ____
Age: Birth date: ____________ Day of Last Physical Examination:
What is the reason for your visit?:
Conditions
What, If any, serious conditions have you experienced in the past year?:
If there isn’t enough space, please provide an attached list of all allergies, medications, and supplements.
Medications/Supplements Allergies
Medication Name Dosage
______
Pharmacy Name: Phone: ( )- __
Symptoms
Check the box if you currently have or have had any of these symptoms in the past year:
GENERAL GASTROINTESTINAL EYE/EAR/NOSE/THROAT WOMEN ONLY
Chills Poor appetite Bleeding gums Abnormal PAP smear
Depression Bloating/Gas Blurred/double vision Bleeding between cycles
Dizziness Bowel changes Difficulty swallowing Breast lumps
Fainting Constipation Earaches Extreme menstrual pain
Fever Diarrhea Ear discharge Hot flashes
Forgetfulness Excessive hunger Hay fever Loss of Libido/sex drive
Headache Excessive thirst Hoarseness Nipple discharge
Loss of Sleep Hemorrhoids Loss of hearing Vaginal dryness
Loss of Weight Indigestion Nosebleeds Vaginal discharge
Nervousness Nausea/Vomiting Persistent cough Painful intercourse
Numbness Rectal bleeding Ringing in the ears Vaginal pain
Sweats Stomach pain Sinus problems Other: _____________
Vision flashes/Halos
GENITO/URINARY Date of Last Menstrual Period:
CARDIOVASCULAR
Blood in Urine ______________
Chest pain MEN ONLY
Frequent Urination
High blood pressure Breast lumps Date of Last Pap: _________
Lack of Bladder Control
Low blood pressure Difficulty with erections
Painful Urination
Poor circulation Lump in testicles Last Mammogram:________
SKIN Rapid heart beat Sore penis
Are you Pregnant? ________
Easy Bruising Swelling in the ankles Pain with intercourse Number of Children:_______
Hives/Itching Varicose veins Other: _______________
Changes in Moles Other:______________
Rash
Scars
Sores that don’t heal
FAMILY HISTORY; Fill in health information about your immediate family
State of Age At Cause of
Relation Age Gender Health Death Death Check if, Your blood relative had any of the following
Mother Disease Relationship to you
Father Arthritis, Gout
Siblings Asthma, Hay Fever
Cancer
Chemical Dependency
Diabetes
Heart Disease, Stroke
High Blood Pressure
Kidney Disease
Tuberculosis
Other:
IMPORTANT HOSPITALIZATIONS; In the past 10 years PREGNANCIES; Attach list if more than 5 births
Year Hospital Reason Year Of Birth Sex of Birth Complications, If Any
HEALTH HABITS OCCUPATIONAL
Substance How much Name Of Occupation:
Caffeine Stress
Tobacco Heavy lifting
Recreational
Drugs Hazardous Substances
Alcohol Other
I, , acknowledge and agree that I have read a copy of
the physician’s Notice of Privacy Practices and that a copy can be provided upon request.
I, , also to my knowledge have filled out the above form
With health history information is complete and correct. I understand that is my responsibility
To inform the physician in charge of my care if I, or my minor child, ever have a change in health
Signature of Patient, Parent, Guardian, or Personal Representative Date
Please print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient